Nokea
A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?
- A. Color of sputum
- B. Lung sounds
- C. Saturation level
- D. White blood cell count (WBC)
Correct Answer: D
Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.
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The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?
- A. Physician
- B. Physical therapist
- C. IV therapist
- D. Enterostomal therapist
Correct Answer: D
Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.
A client with acquired immunodeficiency syndrome is admitted with a diagnosis of pneumocystis jirovecki pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based on his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for self-injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and attempts to remove medical devices indicate a risk for self-injury, making this the priority nursing diagnosis.
The nurse is interacting with a client who has just been told she is HIV positive. The client asks the nurse when she will die. What should the nurse plan to include when replying?
- A. HIV positive means that the client has antibodies against the virus. It does not mean that the client has AIDS. Most people do not develop AIDS or die for many years.
- B. Most persons who are HIV positive live 5 to 10 years with aggressive treatment.
- C. Life expectancy depends on whether there is further exposure to the virus.
- D. The progression from HIV positive to full-blown AIDS is usually quite rapid.
Correct Answer: A
Rationale: HIV positivity indicates antibodies, not AIDS; with modern antiretroviral therapy, progression is slow, and many live for decades, unlike rapid progression or fixed timelines.
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?
- A. Pelvic tip downward
- B. Right leg lengthening
- C. Ortolani sign
- D. Characteristic limp
Correct Answer: D
Rationale: Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking, indicating hip joint instability.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.